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51 Cards in this Set
- Front
- Back
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Opening of the encounter: |
“Mr. Jones, hello; I am Dr. Orih. It’s nice to meet you. I’d like to ask you somequestions and examine you today.” “How can I help you today?” “What brought you to the hospital/clinic today?” “What made you come in today?” “What are your concerns?” |
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Pain: |
“Do you have pain?” “When did it start?” “How long have you had this pain?” “How long does it last?” “How often does it come on?” “Where do you feel the pain?” “Can you show me exactly where it is?” “Does the pain travel anywhere?” “What is the pain like?” “Can you describe it for me?” “What is the character of the pain? For example, is it sharp, burning, cramping,or pressure-like?” “Is it constant, or does it come and go?” “On a scale of 1 to 10, with 10 being the worst pain you have ever felt, howwould you rate your pain?” “What brings the pain on?” “Do you know what causes the pain to start?” “Does anything make the pain better?” “Does anything make it worse?” “Have you had similar pain before?” |
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Nausea: |
“Do you feel nauseated?”
“Do you feel sick to your stomach?” |
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Vomiting: |
“Did you vomit?”
“Did you throw up?” “What color was the vomit?” “Did you see any blood in it?” |
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Cough: |
“Do you have a cough?”
“When did it start?” “How often do you cough?” “During what time of day does your cough occur?” “Do you bring up any phlegm with your cough, or is it dry?” “Does anything come up when you cough?” “What color is it?” “Is there any blood in it?” “Can you estimate the amount of the phlegm? A teaspoon? A tablespoon? A cupful?” “Does anything make it better?” “Does anything make it worse?” |
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Headache: |
“Do you get headaches?”
“Tell me about your headaches.” “Tell me what happens before/during/after your headaches.” “When do your headaches start?” “How often do you get them?” “When your headache starts, how long does it last?” “Can you show me exactly where you feel the headache?” “What causes the headache to start?” “Do you have headaches at certain times of the day?” “Do your headaches wake you up at night?” “What makes the headache worse?” “What makes it better?” “Can you describe the headache for me, please? For example, is it sharp, dull, pulsating, pounding, or pressure-like?” “Do you notice any change in your vision before/during/after the headaches?” “Do you notice any numbness or weakness before/during/after the headaches?” “Do you feel nauseated? Do you vomit?” “Do you notice any fever or stiff neck with your headaches?” |
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Fever: |
“Do you have a fever?”
“Do you have chills?” “Do you have night sweats?” “How high is your fever?” |
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Shortness of breath: |
“Do you get short of breath?”
“Do you get short of breath when you’re climbing stairs?” “How many steps can you climb before you get short of breath?” “When did it first start?” “When do you feel short of breath?” “What makes it worse?” “What makes it better?” “Do you wake up at night short of breath?” “Do you have to prop yourself up on pillows to sleep at night? How many pillows do you use?” “Have you been wheezing?” “How far do you walk on level ground before you have shortness of breath?” “Have you noticed any swelling of your legs or ankles?” |
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Urinary symptoms: |
“Has there been any change in your urinary habits?”
“Do you have any pain or burning during urination?” “Have you noticed any change in the color of your urine?” “How often do you have to urinate?” “Do you have to wake up at night to urinate?” “Do you have any difficulty urinating?” “Do you feel that you haven’t completely emptied your bladder after urination?” “Do you need to strain/push during urination?” “Have you noticed any weakness in your stream?” “Have you noticed any blood in your urine?” “Do you feel as though you need to urinate but then very little urine comes out?” “Do you feel as though you have to urinate all the time?” “Do you feel as though you have very little time to make it to the bathroom onceyou feel the urge to urinate?” |
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Bowel symptoms: |
“Has there been any change in your bowel movements?”
“Do you have diarrhea?” “Are you constipated?” “How long have you had diarrhea/constipation?” “How many bowel movements do you have per day/week?” “What does your stool look like?” “What color is your stool?” “Is there any mucus or blood in it?” “Do you feel any pain when you have a bowel movement?” “Did you travel recently?” “Do you feel as though you strain to go to the bathroom or a very small amount of feces comes out?” “Have you lost control of your bowels?” “Do you feel as though you have very little time to make it to the bathroom once you have the urge to have a bowel movement?” |
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Weight: |
“Have you noticed any change in your weight?” “How many pounds did you gain/lose?”
“Over what period of time did it happen?” “Was the weight gain/loss intentional?” |
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Appetite: |
“How is your appetite?”
“Has there been any change in your appetite?” “Are you getting full too quickly during a meal?” |
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Sleep:
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“Do you have any problems falling asleep?”
“Do you have any problems staying asleep?” “Do you have any problems waking up?” “Do you feel refreshed when you wake up?” “Do you snore?” “Do you feel sleepy during the day?” “How many hours do you sleep?” “Do you take any pills to help you go to sleep?” |
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Diet:
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“Has there been any change in your eating habits?”
“What do you usually eat?” “Did you eat anything unusual lately?” “Are there any specific foods that cause these symptoms?” “Is there any kind of special diet that you are following?” |
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Dizziness: |
“Do you ever feel dizzy?”
“Tell me exactly what you mean by dizziness.” “Did you feel the room spinning around you, or did you feel lightheaded as if you were going to pass out?” “Did you black out or lose consciousness?” “Did you notice any change in your hearing?” “Do your ears ring?” “Do you feel nauseated? Do you vomit?” “What causes this dizziness to happen?” “What makes you feel better?” |
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Joint pain: |
“Do you have pain in any of your joints?”
“Have you noticed any rash with your joint pain?” “Is there any redness? or swelling of the joint?” “Are you having difficulty moving the joint?” |
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Travel history: |
“Have you traveled recently?”
“Did anyone else on your trip become sick?” |
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Past medical history: |
“Have you had this problem or anything similar before?”
“Have you had any other major illnesses before?” “Do you have any other medical problems?” “Have you ever been hospitalized?” “Have you ever had a blood transfusion?” “Have you had any surgeries before?” “Have you ever had any accidents or injuries?” “Are you taking any medications?” “Are you taking any over-the-counter drugs, vitamins, or herbs?” “Do you have any allergies?” |
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Family history: |
“Does anyone in your family have a similar problem?”
“Are your parents alive?” “Are they in good health?” “What did your mother/father die of?” “Are your brothers or sisters alive?” |
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Social history: |
“Do you smoke?”
“How many packs a day?” “How long have you smoked?” “Do you drink alcohol?” “What do you drink?” “How much do you drink per week?” “Do you use any recreational drugs such as marijuana or cocaine?” “Which ones do you use?” “How often do you use them?” “Do you smoke or inject them?” “What type of work do you do?” “Where do you live? With whom?” “Tell me about your life at home.” “Are you married?” “Do you have children?” “Do you have a lot of stressful situations on your job?” “Are you exposed to environmental hazards on your job?” |
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Alcohol history: |
“How much alcohol do you drink?”
“Tell me about your use of alcohol.” “Have you ever had a drinking problem?” “When was your last drink?” Administer the CAGE questionnaire: “Have you ever felt a need to cut down on drinking?” “Have you ever felt annoyed by criticism of your drinking?” “Have you ever had guilty feelings about drinking?” “Have you ever had a drink first thing in the morning (‘eye opener’) to steady your nerves or get rid of a hangover?” |
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Sexual history: |
“I would like to ask you some questions about your sexual health and practice.”
“Are you sexually active?” “Do you use condoms? Always? Other contraceptives?” “Are you sexually active? With men, women, or both?” “Tell me about your sexual partner or partners.” “How many sexual partners have you had in the past year?” “Do you currently have one partner or more than one?” “Have you ever had a sexually transmitted disease?” “Do you have any problems with sexual function?” “Do you have any problems with erections?” “Do you use any contraception?” “Have you ever been tested for HIV?” |
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Gynecologic/obstetric history: |
“At what age did you have your first menstrual period?”
“How often do you get your menstrual period?” “How long does it last?” “When was the first day of your last menstrual period?” “Have you noticed any change in your periods?” “Do you have cramps?” “How many pads or tampons do you use per day?” “Have you noticed any spotting between periods?” “Have you ever been pregnant?” “How many times?” “How many children do you have?” “Have you ever had a miscarriage or an abortion?” “Do you have pain during intercourse?” “Do you have any vaginal discharge?” “Do you have any problems controlling your bladder?” “Have you had a Pap smear before?” |
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Pediatric history: |
“Was your pregnancy full term (40 weeks or 9 months)?”
“Did you have routine checkups during your pregnancy? How often?” “Did you have any complications during your pregnancy/during your delivery/ after delivery?” “Was an ultrasound performed during your pregnancy?” “Did you smoke, drink, or use drugs during your pregnancy?” “Was it a vaginal delivery or a C-section?” “Did your child have any medical problems after birth?” “When did your child have his first bowel movement?” |
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Growth and development:
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“When did your child first smile?”
“When did your child first sit up?” “When did your child start crawling?” “When did your child start talking?” “When did your child start walking?” “When did your child learn to dress himself?” “When did your child start using short sentences?” |
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Feeding history: ”
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“Did you breast-feed your child?”
“When did your child start eating solid food?” “How is your child’s appetite?” “Does your child have any allergies?” “Is your child’s formula fortified with iron?” “Are you giving your child pediatric multivitamins? |
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Routine pediatric care:
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“Are your child’s immunizations up to date?” “When was the date of your child’s last routine checkup?”
“Has your child had any serious illnesses?” “Is your child taking any medications?” “Has your child ever been hospitalized?” |
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Psychiatric history:
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“Tell me about yourself and your future goals.”
“How long have you been feeling unhappy/sad/anxious/confused?” “Do you have any idea what might be causing this?” “Would you like to share with me what made you feel this way?” “Do you have any friends or family members you can talk to for support?” “Has your appetite changed lately?” “Has your weight changed recently?” “Tell me how you spend your time/day.” “Do you have any problems falling asleep/staying asleep/waking up?” “Has there been any change in your sleeping habits lately?” “Do you enjoy any hobbies?” “Do you take interest or pleasure in your daily activities?” “Do you have any memory problems?” “Do you have difficulty concentrating?” “Do you have hope for the future?” “Have you ever thought about hurting yourself or others?” “Do you think of killing yourself or ending your own life?” “Do you have a plan to end your life?” “Would you mind telling me about it?” “Do you ever see or hear things that others can’t see or hear?” “Do you hold beliefs about yourself or the world that other people would find odd?” “Do you feel as if other people are trying to harm or control you?” “Has anyone in your family ever experienced depression?” “Has anyone in your family ever been diagnosed with a mental illness? Would you like to meet with a counselor to help you with your problem?” “Would you like to join a support group?” “What do you think makes you feel this way?” “Have you lost any interest in your social activities or relationships?” “Do you feel hopeless?” “Do you feel guilty about anything?” “How is your energy level?” “Can you still perform your daily functions or activities?” “Whom do you live with?” “How do they react to your behavior?” “Do you have any problems in your job?” “How is your performance on your job?” “Have you had any recent emotional or financial problems?” “Have you had any recent traumatic event in your family?” |
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Daily activities (for dementia patients):
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“Tell me about your day yesterday.”
“Do you need any help bathing/getting dressed/feeding yourself?” “Do you need any help going to the toilet?” “Do you need any help transferring from your bed to the chair?” “Do you ever have accidents with your urine or bowel movements?” “Do you ever not make it to the toilet on time?” “What do you need help with when you eat?” “Do you need any help taking your medications/using the telephone/shopping/preparing food/cleaning your house/doing laundry/getting from place to place/managing money?” |
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Abuse:
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“Are you safe at home?” “Is there any threat to your personal safety at home or anywhere else?” “Does anyone (your husband/wife/parents/boyfriend) treat you in a way that hurts you or threatens to hurt you?” “Can you tell me about the bruises on your arm?”
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HEENT exam: What to say to the patient before and during the exam:
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“I need to examine your sinuses, so I am going to press on your forehead and cheeks. Please tell me if you feel pain anywhere.”
“I would like to examine your eyes now.” “I am going to shine this light in your eyes. Can you please look at the clock on the wall?” “I need to examine your ears now.” “Can you please open your mouth? I need to check the inside of your mouth and your throat.” |
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What to perform during the HEENT exam: Head:
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1. Inspect the head for signs of trauma and scars.
2. Palpate the head for tenderness or abnormalities. |
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What to perform during the HEENT exam: |
1. Inspect the sclerae and conjunctivae for color and irritation.
2. Check the pupils for symmetry and reactivity to light 3. Check the extraocular movements of the eyes. 4. Check visual acuity with the Snellen eye chart. 5. Perform a funduscopic exam. Remember the rule “right-right-right” (ophthalmoscopein examiner’s right hand—patient’s right eye—examiner’sright eye) and the rule “left-left-left” (ophthalmoscope in examiner’s lefthand—patient’s left eye—examiner’s left eye). |
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Ears:
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1. Conduct an external ear inspection for discharge, skin changes, or masses.
2. Palpate the external ear for pain (otitis externa); do the same for the mastoid. 3. Examine the ear canal and the tympanic membrane using an otoscope. (Don’t forget to use a new speculum for each patient.) 4. Conduct the Rinne and Weber tests. |
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Nose:
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1. Inspect the nose.
2. Palpate the nose and sinuses. 3. Inspect the nasal turbinates and the nasal septum with a light source. |
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Mouth and throat:
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1. Inspect with a light.
2. Look for mucosal ulcers, and inspect the uvula and under the tongue formasses. |
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Cardiovascular exam: What to say to the patient before and during the exam:
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“I need to listen to your heart.”
“Can you hold your breath, please?” “Can you sit, please?” “Can you turn to your left side, please?” “I am going to examine your legs to check for fluid retention. Is that okay with you?” “I need to check the pulse in your arms and legs now.” |
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What to perform during the cardiovascular exam:
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When examining the heart, do not lift up the patient’s gown. Rather, pull the gown down the shoulder, exposing only the area to be examined.
Listen to the carotids for bruits. (Classically the bell of the stethoscope is used to listen for slow, turbulent blood flow, but the diaphragm is also acceptable in this scenario.) Look for JVD. Remember to raise the head of the bed to 45 degrees. Palpate the chest for the PMI, retrosternal heave, and thrills. Listen to at least two of the four cardiac areas. (Listen to the mitral area with the patient on his left side.) Listen to the base of the heart with the patient leaning forward. Check for pedal edema. Check the peripheral pulses. Advanced techniques such as pulsus paradoxus or the Valsalva maneuver are time-consuming and unlikely to provide essential information. |
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Pulmonary exam: What to say to the patient before and during the exam:
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“I need to listen to your lungs now.”
“Can you take a deep breath for me, please?” “Can you say ‘99’ for me, please?” “I am going to tap on your back to check your lungs. Is that okay with you?” |
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What to perform during the pulmonary exam:
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Inspect: Examine the shape of the chest, respiratory pattern, and deformities.
Palpate: Look for tenderness and tactile fremitus. Percuss. Auscultate for egophony, wheezes, and crackles. Examine both the front and the back of the chest. Don’t percuss or auscultate through the patient’s gown. Don’t percuss or auscultate over the scapula. Allow a full inspiration and expiration in each area of the chest. |
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Abdominal exam: What to say to the patient before and during the exam:
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“I need to examine your belly/stomach now.”
“I am going to listen to your belly now.” “I am going to press on your belly. Tell me if you feel any pain or discomfort.” “Now I need to tap on your belly.” “Do you feel any pain when I press in or when I let go? Which hurts more?” |
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What to perform during the abdominal exam:
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Inspect.
Auscultate (always auscultate before you palpate the abdomen). Percuss. Palpate: Start from the point that is farthest from the pain; be gentle on the painful area, and don’t try to reelicit the pain. Check for rebound tenderness, CVA tenderness, the obturator sign, the psoas sign, and Murphy’s sign. Check the liver span. |
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Neurologic exam: What to say to the patient before and during the exam—mini-mental statusexam questions:
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“I would like to ask you some questions to test your orientation.”
“I would like to check your memory and concentration by asking you some questions.” “Can you tell me your name and age?” “Do you know where you are now?” “Do you know the date today?” Show the patient your pen and ask, “Do you know what this is?” “Now I would like to ask you some questions to check your memory.” “I will name three objects for you, and I want you to repeat them immediately, okay? Chair, bed, and pen.” (Tests immediate memory.) “I will ask you to repeat the names of these three objects after a few minutes.”(Tests short-term memory.) “Do you remember what you had for lunch yesterday?” (Tests recent memory.) “When did you get married?” (Tests distant memory.) “Now can you repeat for me the names of the three objects that I mentionedto you?” (Tests short-term memory.) “Are you left-handed or right-handed?” “I will give you a piece of paper. I want you to take the paper in your righthand, fold the paper in half, and put it on the table.” (Three-step command.) “Now I want you to write your name on the paper.” “I want you to count backward starting with the number 100,” or “Take 7away from 100 and tell me what number you get; then keep taking 7 awayuntil I tell you to stop.” (Tests concentration.) “Spell world forward and backward.” (Tests concentration.) “What would you do if you saw a fire coming out of a paper basket?” (Testsjudgment.) |
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What to say to the patient before and during the exam—neurologic examquestions:
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“I am going to check your reflexes now.”
“I am going to test the strength of your muscles now.” “This is up and this is down. Tell me which direction I am moving your big toe.” “Can you walk across the room for me, please?” |
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What to perform during the neurologic exam: Mental status examination: Orientation, memory, concentration. Cranial nerves:
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1. II: Vision.
2. III, IV, VI: Extraocular movements. 3. V: Facial sensation, muscles of mastication. 4. VII: “Smile, lift your brows, close your eyes and don’t let me open them.” 5. IX, X: Symmetrical palate movement, gag reflex. 6. XI: “Shrug your shoulders.” 7. XII: “Stick out your tongue.” |
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Motor system:
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1. Passive motion.
2. Active motion: Arms—flexion (“pull in”), extension (“push out”); wrists—flexion (“push down”), extension (“pull up”). 3. Hands: “Spread your fingers apart; close your fist.” 4. Legs: Knee extension (“kick out”), knee flexion (“pull in”). 5. Ankles: “Push on the gas pedal.” |
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Reflexes:
Sensory system: Cerebellum: Meningeal signs: |
Reflexes: Biceps, triceps, brachioradialis, patellar, Achilles, Babinski.
Sensory system: Sharp (pin)/dull (cotton swab), vibration, position sense. Cerebellum: Finger-to-nose, heel-to-shin, rapid alternating movements, Romberg’s sign, gait. Meningeal signs: Neck stiffness, Kernig’s sign, Brudzinski’s sign. |
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Joint exam: What to say to the patient before and during the exam:
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“Tell me if you feel pain anywhere.”
“I am going to examine your knee/ankle now.” |
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What to perform during the joint exam:
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Inspect and compare the joint with the opposite side.
Palpate and check for joint tenderness. Check for joint effusion. Check for crepitus. Check joint range of motion both by having the patient move the joint (active) and by having the examiner move it (passive). Check for warmth, swelling, and redness. Check for instability. Check gait. For the knee: Conduct a Lachman test, an anterior drawer test, a posterior drawer test, and McMurray’s test, and check the stability of the medial and lateral collateral ligaments. For the shoulder: Check adduction and internal rotation, abduction and external rotation, Neer’s test, Hawkins’ test, the drop arm test for supraspinatus tears, and O’Brien’s test. For the wrist: Check for Tinel’s sign, Phalen’s sign, signs or symptoms of Dupuytren’s contracture, and Heberden’s nodes. For the elbow: Check for lateral and medial epicondylitis. For the hip: Check abduction, adduction, flexion, and extension. For the lower back: Conduct a leg raise test. |
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Useful scales:
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Reflexes (0–4), with 0 being completely areflexic:
1: Hyporeflexia 2: Normal reflexes 3: Hyperreflexia 4: Hyperreflexia plus clonus (test the ankle and the knee) Strength (0–5), with 0 representing an inability to move the limb: 1: Can move limb (wiggle toes) 2: Can lift limb against gravity 3: Can lift limb with one-finger resistance from the examiner 4: Can lift limb with two-finger resistance from the examiner 5: Has full strength Pulses (0–4), with 0 representing pulselessness: 1: Weak pulse 2: Regular pulse 3: Increased pulse 4: Pounding pulse |
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if running out of time for mini-mental exam, what do you do? |
ask about their name, where they are and what day it is |
